Current thinking on Lower Eyelids

Over the years the approach to rejuvenate the lower eyelids has gone through many changes. Prior to the mid 1980’s the accepted gold standard of treatment was to remove as much fat, skin and “excess” muscle as possible. These techniques were championed by virtually every reputable surgeon at that time and results from such procedures were published in all of the most highly regarded textbooks. As these results are now revisited in 2011 it is simply astonishing what used to be regarded as a “good result”! Careful attention to those older results shows retraction for the lower lid margin with too much while exposed and rounding of the lid. There is hollowing around the eyes and eversion of the lashes as well as changes in the angle between the upper and lower lids. Not only are these prior “great results” unattractive, they actually make the person look older!

The trend subsequently moved away from removing skin and muscle, and surgeons began to remove fat from inside the eyelid without the creation of a visible scar. This technique called “transconjunctival lower lid blepharoplasty” was an improvement because less retraction and scarring occurred but it still left patients looking hollowed out. The removal of fat without simultaneous tightening of the skin left the lid skin looking “deflated” and crepey with more lines. The hollow created a shadow in certain lighting that left patients looking tired and older. In order to address these issues some surgeons began taking just a “pinch” of skin without much dissection or using various machines (such as radiofrequency or lasers) to tighten the skin. While these approaches often improved results they occasionally made no significant difference or created some subtle retraction or pigment changes that were unwelcome.

In the late 1990’s some of us began to critically analyze the results of our tried and true techniques. It was apparent that we were not doing a great job at rejuvenating the lower eyelid area so a new approach developed that involved repositioning the fat from inside of the orbit to the hollow area beneath the rim. Moving the fat and redistributing it from where there is too much to where there is not enough allows for evening the contours to get rid of the shadows that make people look tired. This technique also maintains the volume under the skin and thus prevents any increased laxity from developing. I do this from an incision inside the eyelid so there is no visible incision. This method of fat repositioning is different from fat transfer, which involves moving fat taken from another part of the body to the under eye area. Fat transfer requires that the fat grafts obtain a new blood supply in their new locale and often times the fat just reabsorbs or takes unevenly, resulting in lumps and bumps.

While patients do sometimes stay bruised for two weeks this procedure provides for the most natural looking and rejuvenative results that I have yet seen in the past 18 years. While I do not do this on every single patient, most of the lower lids are handled in this fashion. As an alternative to this procedure I may suggest using Restylane to fill in the hollows. While this is a non-surgical procedure and much less costly than surgery the results are not as profound because the bulge of fat still remains…we just inject around it to make it appear flat. Additionally, patients can be bruised for two weeks from injections in this area since the skin is very thin and the tissue is very vascular.